Healthcare Provider Details

I. General information

NPI: 1386746378
Provider Name (Legal Business Name): STACY C. DAVIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 11/01/2023
Certification Date: 11/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 WINTER ST
AUGUSTA GA
30904-4708
US

IV. Provider business mailing address

1450 WINTER ST
AUGUSTA GA
30904-4708
US

V. Phone/Fax

Practice location:
  • Phone: 706-364-3371
  • Fax: 706-364-3380
Mailing address:
  • Phone: 706-364-3371
  • Fax: 706-364-3380

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number043030
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: